Reporting Log

Program Tool

WWW.VIRTUALLABSCHOOL.ORG

ACTIVITY ID: 15396

Name

Certifier

Date

It is important to retain some information about staff members' observations. You can use this form to help staff members maintain records of what they notice. It can be useful when reporting suspicions of child abuse and neglect. Be sure, though, that all observations or records of reports are kept separate from the child's files in the office. This information is confidential.

Child's Name	Today's Date

What signs or symptoms were observed? Be specific. Include information about what the child or adult said and the location of the injury on the child's body.
What time and date were the signs or symptoms originally observed?
Where was the observation made (e.g., classroom, playground)?
Who made the observation?
What steps were taken? Who was contacted or notified (i.e., FAP, CPS, law enforcement)? Include the name of the person or agency contacted and the date and time of contact.
Was the family notified? If so, include the name of the person contacted and the date and time of contact.

Notes (Describe any follow-ups or special circumstances impacting this event.)

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